BLD2020-0534+City_Application+5.24.2020_1.59.26_PMBUILDING PERMIT Office Use Only
APPLICATION Permit#:
Development Services
Building Division TYPE OF PERMIT (Provide Details on Page 2)
121 5th Ave N / Edmonds, WA 98020
425.771.0220
'tic, 1 V'9"
For handouts, submittal requirements go to: www.edmondswo.aov.
To apply for permits, schedule inspections, or check application status
go to: www.mvbuildingpermit.com
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: _65Q �OWI kAiN
Parcel: 00 & et '7 000c) ISO 0
Lot /Unit/Suite #: Subdivision:
BUSINESS OR PROPERTY OWNER:
r1 Name: ry i 0 t F GAS Me. (�IAt 4414
12
Mailing Address: o SarA T• fw+t� fi
City/State/Zip:
Phone #:
Email
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? Yes l� No
I own, reside in, or will reside in the completed structure. This
installation is being made on property that I own which is not
intended for sale, lease, rent, or exchange according to RCW
18.27.090.
Owner Signature:
APPLICANT / CONTACT INFORMATION:
Name of Applicant: N j c le_o U*S 'i�• n citJ
Mailing Address: ZZ� .S°" H A V& %yV60l
City/State/Zip: ii�''/ ® $1 o .
Phone #: �_ l) 71 &T -s-z i 8
E-mail: IA. ijo'v $+a e0 piiownlo %* a if,."
GENERAL CONTRACTOR: (if different from applicant)
General Contractor:
Mailing Address:
City/State/Zip:
Phone #:
E-mail:
STATE UBI M
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I M (CCB) & EXPIRATION DATE:
❑Accessory Structure/
Detached Garage
❑ Addition
Demolition
Mechanical
New Single Family/Duplex
Plumbing
Fire Sprinkler
Remodel
New Commercial/Mixed Use
Re -Roof
Signs
❑ Tank
Tenant Improvement
❑ Other
Remodel Permit fees are based on:
The value of the work performed. Indicate the value (rounded to
the nearest dollar) of all equipment, materials, labor, overhead,
and the profit or the work indicated on this application.
Valuation: ®Od
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement scl ft: Finished❑ Unfinished ❑
1st Floor, sci ft:
2nd Floor, scl ft:
Garage/Carport:, scl ft:
Deck/Covered Porch/Patio:
# of NEW Bedrooms: # of NEW Bathrooms:
PROJECTDESCRIPTION
0,01m big e-t-, I $'� i M, Nam "
NSA OV Ip: '� Q M i
- Ili✓ W)i°l�f �/S� POO",
I certify that the information I have provided on this form/application is true,
correct and complete, and that I am the property owner or duly authorized
agent of the property owner to submit a permit application to the City of
Edmonds.
Print Name: 1%"MdN
Signature: Date �004
COMMERCIALGENERAL DATA
Occupancy Group(s): Occupant Load(s):
Type(s) of Construction:
Fire Sprinklers: Yes❑ Novi
WA STATE ENERGY CODE: If your project affects the building envelope,
mechanical systems, and/or lighting, you must complete the
appropriate WSEC forms.
DEFERRED SUBMITTALS: All commercial building permits that will require
associated plumbing, mechanical, fire sprinkler, and/or fire alarm
permits are applied for separately.
TI / CHANGE OF USE / NEW BLDG: Include TRAFFIC IMPACT worksheet
EQUIPMENTMECHANICAL •
BTU,s Gas / Elec / Other Qty
A/C Unit /Compressor
�� V
Air Handler/VAV
Boiler
D
Dryer Duct
2„
Exhaust Fans
7
Fireplace
Furnace
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
e�
Other:
COUNTSPLUMBING FIXTURE • • or re piped)
Qty Qty
Clothes Washer
�,
Tub/ Showers
Dishwasher
Backflow Device (RPBA, DCDA, AVB)
Drinking Fountain
®
Pressure Reduction/ Regulator Valve
Floor Drain/Sink
j
11
Refrigerator Water Supply
Hose Bibs
Water Heater - Tankless? Y or N
Hydronic Heat
®
Water Service Line
Sinks
Other:
Toilets
30Other:
CONNECTION COUNTSd or re piped)
BTUs Qty BTUs Qty
A/C Unit
Outdoor BBQ J Fire pit
Boiler
Stove/Range/Oven
Dryer
Water Heater
Fireplace/ Insert
Other:
Furnace
'
Other:
COUNTSMEDICAL GAS, AIR VACUUM
Relocated . piped)
Qty Qty
Carbon`Dioxide
®
Nitrous Oxide
0
Helium
®
Oxygen
Medical Air
0
Other:
Medical - Surgical Vacuum Other: d
DEMOLITION
Type of structure to be demolished: N,
Square footage of structure to be demolished:
AHERA Survey done? Y❑/ NFI
PSCAA Case #:
Critical Areas Determination:
Study Required[:] Conditional Waiver El Waiver❑
Fill in Place ❑ Fill Material:
Removal ❑
Size of Tank (Gallons)
Critical Areas Determination:
Study Required Conditional Waiver Waiver
GRADE/FILL/EXCAVATE
Grading: Cut cubic yards
Fill cubic yards
Cut / Fill in Critical Area: Yes ❑ No
GENERAL PROVISIONS
APPLICATIONS: Applications are valid for a maximum of 1 year.
ESLHA Applications, 2 years.
LICENSING: All contractors and subcontractors are required to be licensed
with Washington State Department of Labor & Industries and have a
current City of Edmonds Business License.